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psv.nuevr County <br /> �) Safety and Buildings Division Burnett <br /> ' B 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number on be filled in by Cu.) <br /> Madison,W153707-7162 <br /> Sanitary Permit Application swejT��9s3�.(,on Number <br /> In aceordanec with SPS 383 21(2),Wis,Adm.Curie,submivinn of this f to me Wro,priate go,emm atal unit vW+" 1 (CII I� <br /> is manned prior to obtaining a sanitary permit. Note:Application forms for stale-owned lx)WTS me sohmined 0 Pmjeet Address(if dinerenl that mailing address) <br /> marroNe 0.T s in ax, m Safety and the <br /> Pdvsirmal w,s.1 . Personal information Sari proviM may be used far secondary <br /> in mcordance with the Privac Lew,s. IS Ib I)m,Suis. 1234 Roberts RJ. <br /> I. Application Information-Pleam Print All Information <br /> Propny Gwner's NameI Pri a <br /> Catherine Jenny3 ^ 07-028-2-40-14-24-505-004-015000 <br /> Property(toners Mailing Address _ "''""""ffff���� q/ ftpmv Lawion <br /> 80 Weslern Ave.North 4404 <br /> CorL Lot 4 <br /> 01'.Stake zip Cade Ph..Number A,__a Swam 24 <br /> St. Paul MN 55102 Icirelc unc) <br /> II.Type of Build Log(ehak all that apply) Lot 0 T40 N; B 14 GaW <br /> 0f or 21'a of,Dwelling-NumMrof Pontoons 2 14a1'•unrecorded plat Subdivision Name <br /> Block <br /> ❑Publir.Y;ummcrciil-Liescribe Ux <br /> ❑City of <br /> ❑$Iffie Owned-IkscriM Ilse CSM Number ❑ Villageof <br /> ®'raven of Scan <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) - -qQ - <br /> A' ❑ New System 12 Rcplacenamt S)stem ❑'ro aunenJllolding Tank Replan axnl Only ❑Other Mortification to lNeamg System(expoin) <br /> R. ❑ Permit Renewal ❑ Permit Revision ❑Change of Plumber ❑I4mmit l om,tir tO New List Previous Permit Number and[Tore Issued <br /> lief expiration Owxr <br /> IV.Type of POWTS S stem/Com onenNDevice: Chale dl[het a 1 <br /> ®Nan-Pres...ved ln-cround ❑ Pmslm,rd ln-Cmund ❑ At-0rade ❑M...1124 mr.f.itar ,sid) ❑Mmmd<24 in.of%dwde sail <br /> ❑ ILolding Tank ❑(Mer Uisprxal COmpmrnt kxplain) ❑Pretreatment Ibvice(c plains <br /> V.DLs rsaVl'reatment Area Information: <br /> 1Mign Flaw(god) 0.sign Soil Application Rwogp&O Dispersal Ana Required(st) Dispnal A.Proposed(0) S)srern Elcvmion <br /> 300 .45 667 EISA of 700 96.10'-95.60'-94.50' <br /> VI.'rank Info Capacity in Tool aof Manufaaum <br /> cellons Gallons Units cis o e u <br /> New looks P:nis ing Tanks u V <br /> i U ? Ci 6 <br /> septicwlolding Tank 1000 1000 X Wieser Concrete X <br /> from,Clamber 600 600 Combination X <br /> VII.Responsibility Statement- L the undersigned,assume respmeability fur instalbrium of 0e PnWTS show.o.the absorbed plana <br /> Plumber's Name(Prod) Plinark's Signature 11 MP/MPRS Nuts, Business Mo.NutnM <br /> Dave Fogerty 221180 715468-7000 <br /> -r <br /> Plumber's Address(Strtn,City,Suu,Alp COM) <br /> 2473 Rolling Green RJ.Spooner W 154801 <br /> VIII.Count /De ariment Use Only <br /> Approved ❑ Di Permit Feebate7pISSN Issuing ;gnuture <br /> ppnry d s <br /> ❑( nerGivenRrawnlbrDenial 2.�j 77aa203 <br /> Ia.Conditions of Approval/Reasons for Disapproval <br /> Much to mmpleu pYrm W aitsprtmatl salmi,mtax Cion,""be"PRrntl Im do.Sot,11 brhes u 6¢ <br />